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2. First Name
3. Last Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Age
16. Emergency Contact Person Relationship:
18. First Name
19. Last Name
21. Phone Number
23. Email Address
25. School Name & Location
27. Highest Grade Completed

    1. 9
    2. 10
    3. 11
    4. 12
28. GPA
30. T-Shirt Size
32. Health Conditions
34. Why are you interested in participating?

    (5-15 sentences/1000 characters)

36. Policy & Procedure
    • Participant MUST BE ages 14-18.
    • Check-In will be no earlier than 8:30 AM.
    • No hats, backpacks, food, jewelry, will be allowed.
    • We are not responsible for personal items this cell phones, tablets, etc.
    • No abusive or profane language.
    • No weapons of any kind.
    • No medication will be dispensed except by parents. Do not bring medication on site. If a child is sick, they should remain at home, or you will be called to pick up your child immediately.
    • Tennis shoes are strongly recommended.
    • Plain shirt with sweatpants, slacks or jeans. NO SAGGING.
    • Emergency information – please keep us informed of any changes in telephone numbers so that we can reach you in case of an emergency.
    • NO FIGHTING OR ARGUING. Keep your hands to yourself and refrain from negative speech.
    • All campers will participate in class sessions and activities.
    • Parents must sign their child in and out.
    • Parents will be contacted if their child becomes unruly during camp.
    • Camp activities end at 4:00 PM. All children must be picked up by 4:00 PM.
    • Any child who violates these rules will be dismissed immediately.
    • Everyone must wear ’Name Badge‘ during camp.
    • If there is a problem with the staff, please report it to Inspector Walker.
    • At the Camp no child will be mistreated.
    • All rules and policies shall be explained to each child.
    • Your child may appear through the media as the West Memphis Fire Department deems appropriate.
    • Information may be collected and shared for the purposes of demonstrating outcomes or secure funding.
    • Provide all relevant health information and history.

    Disclaimer/Waiver

    • I have been provided with the policies and guidelines of “Junior Firefighter Day” and will explain these to my child/children.
    • I agree to indemnify, release and hold harmless the City of West Memphis, Fire Department, West Memphis School District Transit, Park & Recreation Employees and Volunteers from any and all claims or damages for any accident, injury or illness arising out of the use of facilities, equipment and/or participation in activities associated with “Junior Firefighter Day”.
    • I give consent for my child to appear through media as West Memphis Fire Department deems appropriate.
    • Understand that information may be collected and shared for the purposes of demonstrating outcomes or securing funding.
    • I have provided all relevant health information and history.
    • I hereby release the City of West Memphis, its personnel and any institutions with which it is affiliated, from any and all claims and damages of any nature arising from my child’s participation in “Junior Firefighter Day”.
    • I give permission for my child to participate in any field trips on or off-site activities.

    By signing this, I agree to the Policy and Procedures, as well as the disclaimer above and comply with all applicable.

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38. 1. Receive an email copy of this form.
39. Email address

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40. Submit

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